Delirium/Acute confusion
Definition
- Commonly presents with acute confusion, and a change in level of alertness.
- May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
Causes
- Delirium often has a trigger (or more than one) which should be explored and treated where possible.
- Delirium may be associated with poorer outcomes for patients, and is associated with longer term cognitive impairment.
Symptoms
- Commonly presents with acute confusion, and a change in level of alertness.
- May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
- A history of preceding cognitive impairment should be sought.
- A comprehensive review of symptoms and changes to normal routine should be explored.
Signs
- Look for signs of causative conditions
- Consider infection but be aware that acute confusional state is not always a UTI
- Ensure not constipation
- Ensure not in urinary retention
- Explore sensory impairment and ensure has appropriate aids (glasses, hearing aids)
- Pain – assess for pain
- Intracerebral (e.g. stroke) / Infection
- N*utrition (including mouth care)
- Constipation
- Hypoxia / Hypoglycaemia / Hydration
- Metabolic (e.g. hyponatraemia, hypercalcaemia) / Medication
- Environmental (e.g. disturbed sleep, sensory deficits – ensure has glasses, hearing aids)
Blood tests:
- FBC, U&E, LFT, Bone, CRP
- Urine culture if warranted based on clinical assessment
- 4AT test (only takes a couple of minutes)
4A Test
This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating
Age, date of birth, place (name of the hospital or building), current year.
Ask the patient: 'Please tell me the months of the year in backwards order, starting at December.' To assist initial understanding one prompt of “what is the month before December?” is permitted.
Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
| 4 or above | possible delirium +/- cognitive impairment |
|---|---|
| 1-3 | possible cognitive impairment\ |
| 0 | delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) |
Management
- Supportive management
- Treat underlying issues
- Review medications
- Assess for risks to safety (e.g. pressure ulcers, falls)
- Support for patient and informal carers
- Engagement:
- Support reassurance, orientation
- Ensure physical comfort
- Ensure safety at home
- If safety cannot be maintained at home
- If concerns about being acutely unwell / unstable
- If concerns regarding preceding head injury and acute confusion (especially if on anticoagulation) - refer to NICE head injury guidance